Why was my Manitoba Health claim rejected?

What to do and by when

When it applies / when it does not

Where the reason is

• The Remittance Advice is the statement Manitoba Health provides each pay period, at mid-month and month end. (CLMST-4)
• It has two parts: processed claims and pending claims. (CLMST-4)
• The EOB code is the short reason code beside each claim. In the manual's words, EOB codes "explain any changes in payment made by Manitoba Health." (CLMST-4)
• The manual makes reviewing the EOB codes the physician's responsibility. (CLMST-4)
• Manitoba Health publishes its full list of EOB codes. The link is under Source.

Correct and resubmit: the claim had a wrong detail

• "Claims that require a correction to the initial claim must be electronically submitted with the necessary corrections noted in the EOB within six months from the date of the service." (CLMST-1)
• "A query should not be submitted for claims that require a correction." (CLMST-1)
• The six months run from the date of service, not from the date of the Remittance Advice. (CLMST-1)

Query: the claim was right and you disagree

• "if a physician disagrees with an assessment and/or payment of a claim, they may query the claim within six months of the date on the Remittance Advice." (CLMST-1)
• A phone call first may settle it. A medical assessor is the person at Manitoba Health who assesses the claim. "An initial contact with the medical assessor may resolve the assessment to the physician’s satisfaction." (CLMST-7)
• Manitoba Health answers a query within 90 days of receiving it. (CLMST-1; CLMST-7)
• Send each query once. "Duplicate queries and multiple submissions of the same query will not be reviewed." (CLMST-1)
• If Manitoba Health does not answer within 90 days, discuss the claim with Doctors Manitoba. Do the same if the answer does not satisfy you. (CLMST-1; CLMST-7)

Code 77 and code C2

• Code 77 marks a pending claim. "Please do not resubmit or query claims listed as pending." It shows as processed on a later Remittance Advice. (CLMST-5)
• A pending claim still has limits. Manitoba Health may ask for more information; send it within six months of the request. If the claim is not assessed within six months of Manitoba Health having all the information, the manual says to discuss it with Doctors Manitoba. (CLMST-1)
• "Claims received by Manitoba Health more than 6 months after the service date will be rejected with Explanation of Benefits (EOB) code “C2”." (CLMST-3)
• An extension of the six months must be asked for in writing, with details of the extenuating circumstances. (CLMST-3)
• Questions about a Remittance Advice go to Claims Enquiry at Manitoba Health, at 204-786-7355. (CLMST-5)

Worked example

What is often not billed

A rejected claim that is never corrected and resubmitted. A claim rejected for a wrong detail is still care you provided. The wrong detail may be the patient's name or the date of service. It can be paid only if the corrected claim reaches Manitoba Health within six months of the date of service, unless an extension is granted (CLMST-1; CLMST-3). After that, it comes back with code C2 (CLMST-3). The manual lists billing errors among the claims that need supporting documents to be processed (CLMST-2). These include a wrong date of service, tariff or patient. Keep the note for the visit at hand.